Application for Self-Termination Proceedings
(Please fill out and submit to Netloc 691-AC.)

Given Name: ____________________

Citizen ID Number: _ _ _ _ _ - _ _ _ _ _ _ _ _ - _

Profession 1: ____________________

Profession 2: ____________________

Please state, in five hundred words or less, why you wish to initiate a protocol of self-termination:

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Have you previously requested for self-termination within the last ten years? (Yes / No)

Do you have any living first- or second-degree relatives or close relationships? (Yes / No)

If yes, please cite: (Additional lines may be added as necessary.)

Name: ____________________ Nature: ____________________

Name: ____________________ Nature: ____________________

Name: ____________________ Nature: ____________________

Have you consulted with a humanist-psychological counselor or emotor unit within the last ten years? (Yes / No)

If yes, please cite: (Additional lines may be added as necessary.)

Name: ____________________ Month-Year: __________ / _____

Name: ____________________ Month-Year: __________ / _____


All of the information given above is enclosed to the best of my ability, and I shoulder all responsibility for any noted details that are inaccurate or misleading. I am aware that the intentional provision of such erroneous details is a crime punishable by incarceration in a medico-psychological facility of the appropriate discipline.

____________________
(Digital Signatures only.)

Your application for self-termination proceedings will be processed and arbitrated by neutral counsel within five days, after which all results will be transmitted by neural-net communication. During this period of time, your neural files may be scanned and your physical behavior monitored for the purposes of observation. This process will not adversely affect your normal activities.

In the event that your application is rejected, a personalized hominid emotor unit will be assigned to you for psychological development purposes. You will only be allowed to submit future applications for self-termination at least one month after the end of this personal counseling period.